Does mom need cardiac catheterization? Family not sure

Published 6:42 pm, Monday, April 15, 2013

Q: I need advice deciding how to help my mom. She has been very healthy until few years ago when, unfortunately, she was diagnosed with dementia. We got her help and she accepted it and for a while things around her house were stable. Her memory did get worse over time, but we expected it so it was not so scary to witness the change. Then, about a month ago, she got very confused all of sudden. She was rushed to the hospital and was found to have had a small heart attack. She was seen by a competent and pleasant heart doctor. He recommended medications, although he did mention the possibility of a more aggressive procedure called cardiac catheterization. At the time it sounded like overkill so we voted against it. My mom was mostly unaware of what was going on and could not help us with this decision. She was discharged to a rehabilitation nursing home and after three weeks returned home, this time with more care.

Since my mom has been home, she's had symptoms similar to those that brought her to the emergency room almost five weeks ago. Every day she gets sick to her stomach, anxious and in the evening she gets confused. We do have an appointment with the heart doctor but my question is, should we consider aggressive treatment? I am unable to discuss this with my mom, as she gets very easily frustrated and scared. The family is divided. My sister and I would rather stick with medications only. My brother wants to consider all options. Is there a way to help us? How can we predict what is the best way of the treatment for her?

Ann

A: I would like to thank Ann for having approached me with this question. It shows that her family is thoughtful and that they all want the best for their mother. This is not the easiest question to answer, but I think I can try to shed some light on how to make their decision a more informed one.

Elderly parents, even those blessed with an excellent health, are not immune to catastrophic events. Statistically, cardiovascular events like a stroke or heart attack are likely to happen. Some people are truly lucky but, for many of us, the risk of these events is very real.

A specialist, such as e a cardiologist, can answer some questions about the risk associated with a cardiovascular event. Blood work and other tests can fully assess the heart and medications also can be used treat some of the reversible conditions and to minimize damage.

We can assess the strength and viability of the heart, all of its chambers and the larger vessels through a non-invasive procedure called echocardiogram. It is based on the ultrasound technique and is painless and relatively fast with no needles required. It can be a very helpful tool to learn how the heart has been affected and what the next steps should be. Once the person feels better, a stress test can be done. In the test, the patient is asked to walk on a treadmill while his or her heart is checked. In one version of the test, called a "nuclear" stress test, a small amount of a radioactive material is injected into the body. A camera is used capture how the substance travels through the blood and into the heart -- both before the patient exercises and afterward.

In another version of the test, done on patients who are unable to walk, the patient is given a drug that mimics how the heart would respond to exercise.

The heart also can be evaluated by directly visualizing its blood supply during a procedure called cardiac catheterization. First, a thin catheter is threaded through one of the bigger arteries in our body. A special dye is injected and the doctors can observe on a screen which parts of the heart get enough blood and which do not. Sometimes blockages in the heart's blood vessels can be reversed or improved by implanting a special device called a "stent," which strengthens the wall of the vessel.

For some patients with very serious damage to the heart, open heart surgery is the best option. We have less of these procedures now, but still they can be life-saving.

All of these approaches can be offered as a treatment option for a patient suffering with dementia. Dementia, however, does change the game plan. Patients with dementia do not recover the same way as patients without memory disease. There is a high risk of confusion while in the hospital. The ability to follow instructions during the rehabilitation process may be impaired as well. Patients with dementia have much lower functional reserves. What this means is that seemingly trivial problems may result in major losses of the ability to function and mental capacity. Families often find themselves as guardians advocating for their loved ones and making some doctors aware of the dementia diagnosis.

Does this mean that patients with memory loss should never have aggressive procedures or surgery? Not at all. I would not be a geriatrician if I was advocating for the limitations of services for the people who can benefit from them.

Here is how I would suggest approaching this dilemma: First, one of the best predictors of the chance for good recovery is the patient's pre-disease functional ability. If the patient was able, even while battling memory problems, to walk independently without a cane or walker, take care of basic needs, and did not need many medications or major help, the chance of recovery will be higher. If, however, these functions were already compromised, one would advise caution and lean toward a less aggressive approach. The second very important factor is the patient's own preference, if known. Some people just do not want to have a major surgery at, say, age 85. Others truly despise being dependent on others. Families may be able, even without a written document, to agree upon what the loved one would have preferred if he or she could be a part of the discussion. It is extremely critical to try to take our own preferences out of the equation here. This is about our loved one, not us.

Maybe the symptoms described by Ann are not due to her mom's heart condition at all, but rather part of adjusting to being back home and driven by anxiety. This can be assessed easily.

I am quite confident that, with the help of the heart doctor, who was apparently very conscientious and engaged, the most informed decision can be made about treatment.